Management Management of of

Colonoscopic Colonoscopic PerforationPerforation

Joint Hospital Surgical Grand RoundDr Lee Wang Fai Frank

Princess Margaret Hospital

IntroductionIntroduction• Colonoscopy is a frequently used diagnostic

procedure nowadays• Perforation is an uncommon but well recognized

complication of colonoscopy• Potentially life threatening• Management remains controversial

Changing ParadigmChanging Paradigm• Penetrating trauma to the abdomen was the most

common cause of colonic perforation in the past• During World War II , routine colostomy for

management of trauma of colon• Since 1970s, perforation from colonoscopy

became the most common cause of colorectal trauma

Changing ParadigmChanging Paradigm• Standard treatment: early explorative laparotomy

with primary closure or bowel resection, with or without diverting stoma

• 1980s: Reports of successful conservative management (Adair and Hishon1981)

• 1990s: Use of laparoscopic instruments in management of colonoscopic perforation

• 2000s: Endoscopic repair in selected cases• Trend of increasing use of conservative

management and minimally-invasive treatment

Causes of perforationCauses of perforation• Direct mechanical injury

o Forceful passage of tip through diverticulumo Penetration through a tight flexure or loopo Tearing during passage of a narrowed strictureo Lateral pressure of loop of endoscope against a stretched loop of colon

• Barotrauma due to over distension• Therapeutic procedures

o Mechanical trauma of biopsy and dilatation of strictureo Electrical and thermal injury in polypectomy / cauterization

Causes of perforationCauses of perforation• Perforation after therapeutic colonoscopy tend to

be smaller and have a delay in presentation when compared with diagnostic colonoscopy

IncidenceIncidence• Commonly quoted figure: 1 in 1000 (0.1%)• Variable incidence in the literature:

o As low as 0.016% in diagnostic colonoscopyo Up to 5% in therapeutic colonoscopy

Varut Lohsiriwat. Colonoscopic perforation: Incidence, risk factors, management and outcome. World J Gastroenterol. 2010 January 28; 16(4): 425-430.

Incidence: Figures in Incidence: Figures in literatureliterature

T. H Luning, etc. Colonoscopic perforations: a review of 30,366 patients. Surg Endosc. 2007 Jun;21(6):994-7.

Incidence: More Incidence: More recent figuresrecent figures

Varut Lohsiriwat. Colonoscopic perforation: Incidence, risk factors, management and outcome. World J Gastroenterol. 2010 January 28; 16(4): 425-430.

Site of perforationSite of perforation• Most common site:

rectosigmoid colono Sharp angulationo Mobility of sigmoid colono Common diverticular

formationo Pelvic adhesions due to

previous operation or inflammation

Farley DR, etc. Management of colonoscopic perforations. Mayo Clin Proc. 1997 Aug;72(8):729-33.

Risk factorsRisk factors• Therapeutic procedures

o Polypectomyo Dilatation of strictureo Argon plasma coagulationo EMR / ESD

• Older patientso Declining mechanical wall strength due to diverticular diseaseo Greater frequency of colonic pathology requiring therapeutic procedures

• Complete colonoscopy vs flexible sigmoidoscopy• Multiple comorbidities

o DM, cerebrovascular disease, renal impairment, liver disease, dementia

• History of diverticular disease• Previous intra-abdominal surgery

Varut Lohsiriwat. Colonoscopic perforation: Incidence, risk factors, management and outcome. World J Gastroenterol. 2010 January 28; 16(4): 425-430.

DiagnosisDiagnosis• At the time of colonoscopy

o Visualization of extra-intestinal structureo “Difficult procedure”

• After procedureo From several hours to dayso Early symptoms: Abdominal pain and distensiono Late presentation: Fever, peritonitis, shocko 10% asymptomatic

• Investigationso Leukocytosiso Free intraperitoneal air in X-ray (65-87%)1,2

o CT scan / Contrast study

1. Farley DR, etc. Management of colonoscopic perforations. Mayo Clin Proc. 1997 Aug;72(8):729-33.

2. Castellví J, etc. Colonoscopic perforation: useful parameters for early diagnosis and conservative treatment. Int J Colorectal Dis. 2011 Sep;26(9):1183-90.

ManagementManagement• Options:

o Non-operativeo Operative

• Laparotomy / laparoscopic / endoscopic• Repair / bowel resection• Primary anastomosis / staged operation• Diverting stoma

• Factors to considero Mechanism and size of perforationo Severity of symptomso Duration of time between procedure and diagnosiso Adequacy of pre-colonoscopic bowel preparationo Site of perforation (e.g. retroperitoneal)o Patient’s general condition and comorbidities

Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001.

Management: Management: Non-operativeNon-operative

• Patient selection: o Good general condition o Without sign of peritonitis

• Conservative management:o Intravenous fluido Absolute bowel resto Broad-spectrum antibioticso Frequent reassessment

• Surgical intervention should be considered when there is sign of deterioration

• Overall success rate 33-73%

Varut Lohsiriwat. Colonoscopic perforation: Incidence, risk factors, management and outcome. World J Gastroenterol. 2010 January 28; 16(4): 425-430.

Management: Management: OperativeOperative

• Patient selection:o Sign of peritoneal irritation or free gas in X-rayo Concomitant colonic pathology that requires surgery

• Options:o Simple closure of perforation

• Small perforation• No fecal contamination• No concomitant colonic pathology

o Bowel resection with primary anastomosis• Large perforation• Concomitant colonic pathology• No significant intra-abdominal contamination

o Bowel resection without anastomosis / anastomosis with diverting stoma• Fecal peritonitis or extensive tissue inflammation

Management:Management:LaparoscopyLaparoscopy

• Diagnostic laparoscopy• Laparoscopic repair / resection of bowel• Reports of successful laparoscopic repair initially

appeared in the late 1990s• Early diagnosis is crucial• Various techniques described, including usage of

interrupted suture, and endoscopic linear stapler• Good operative results, shorter hospital stay

o Selection bias?

1. Ballester RA, et al. Laparoscopic treatment of endoscopic sigmoid colon perforation: A case report and literature review. Surg Laparosc Endosc Percutan Tech 2006;16:44-46.

2. Mattei P, et al. Laparoscopic repair of colon perforation after colonoscopy in children: report of 2 cases and review of literature. J Ped Surg 2005; 40:1652-2653.

Management:Management:Endoscopic repairEndoscopic repair

• First report of successful endoscopic repair of colonoscopic perforation in 19971

• Only 75 cases reported in literature as at 20082

• Most are small perforations after therapeutic colonoscopy• Early diagnosis, good bowel preparation, small perforation size• Some reports of successful repair of large perforations (up to

35x10mm)• As little air insufflation as possible• Bowel rest, broad-spectrum antibiotics, intravenous fluid, and

close monitoring after procedure• Success rate 69-93%

1. Yoshikane H, et al. Endoscopic repair by clipping of iatrogenic colonic perforation. Gasrointest Endosc 1997; 46: 464-466.

2. Trecca A, et al. Our experience with endoscopic repair of lage colonoscopic perforations and review of the literature. Tech Coloproctol (2008) 12:315-322.

OutcomeOutcome• Morbidity 21-53%

o Surgical site infection is the most common complication

• Mortality 0-26%o Cardiopulmonary complication and multi-organ failure are the leading

causes of death

• Average length of hospital stay 1-3 weeks• Factors predisposing for poor outcome:

o Large perforation siteo Delayed diagnosiso Extensive peritoneal contaminationo Poor bowel preparationo Corticosteroid, anticoagulants or antiplatelet therapyo Prior hospital stayo Advanced age and comorbid diseases

Varut Lohsiriwat. Colonoscopic perforation: Incidence, risk factors, management and outcome. World J Gastroenterol. 2010 January 28; 16(4): 425-430.

ControversiesControversies• Lower mortality rate in non-operative management

than operative treatment?1

o Selection bias?

• Different selection criteria for non-operative management in different centers

• Inconsistency in current literatureo Importance of free gas in X-ray?o Importance of time between procedure and diagnosis?

• Published data in the literature mainly consist of case series onlyo Uncommon complicationo Difficult to perform randomized controlled trialso Spectrum of illness depending on many variables

• Faecal peritonitis vs Clean perforation without soiling

1. Hall C, et al. Colon perforation during colonoscopy: surgical versus conservative management. Br J Surg 1991; 78: 542-544.

ConclusionConclusion• Colonoscopic perforation is a rare complication

following lower gastrointestinal endoscopy• Associated with high morbidity and even mortality• Increasing use of colonoscopy nowadays resulted in

increasing frequency of perforation• No prospective, randomized controlled trials to define

the optimal management• Management should be individualized• Prompt operative management remained standard

treatment• Trend of increasing use of conservative management,

laparoscopic surgical approach, and endoscopic repair in selected patients

Thank youThank you